Thursday, May 27, 2010

As I have traveled around the country giving talks to physicians about health care reform, I am often asked if the new law does enough to control costs - usually by doctors opposed to it.

As I wrote in a Perspectives article that appears in the current issue of the Annals of Internal Medicine, the jury is out, mainly because the most significant cost control initiatives in the law will first be launched on a pilot basis. Although initiatives like Patient-Centered Medical Homes, Accountable Care Organizations, bundled payments, wellness and prevention programs, quality measurement and reporting, and comparative effectiveness research might begin "bending the cost curve," well-respected experts disagree if they do enough.

The more I think about this question, though, the more I wonder if we are looking to the wrong place for the answer. Do conservative critics, especially, want Congress to do more to control costs? Especially since government cost controls usually involve blunt instruments like price controls, cuts in payments to physicians and hospitals, and direct and indirect limits on access to treatments?

Instead of looking to Washington to "bend the cost curve", perhaps we should be looking at the cultural factors present in many of our own communities. As Atul Gawande wrote in his now famous article about McAllen Texas,

"Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for."

Gawande argues that the differences between high cost areas, like McAllen, and lower cost ones, like Grand Junction, Colorado, have more to do with the culture of medicine - "whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue."

In an interview with Ezra Klein, Gawande was asked about the most effective counter arguments against his piece. Gawande replied:

"The idea that these people in McAllen are unhealthier. The idea that it's all malpractice ... [and] pointing out that McAllen is the poorest county in the country. They'd say you couldn't compare it to Mayo. But I didn't. El Paso, which I did compare it to, was the sixth poorest in the United States. They're very closely similar in poverty, in immigration, in physician supply, in rates of disease, and so forth."

(I would add that it is counter-intuitive to say that the malpractice suits are the culprit, since Texas has a state-wide cap on non-economic damages. And yet some parts of Texas spend much less than McAllen, even though the liability cap is the same.)

But is it really fair to pin the blame on physicians for how much the country spends on health care, when patients themselves create demand for more health care when they don't take care of themselves? This makes intuitive sense, until you look at Provo, Utah.

"If there is any place that should have medical spending under control, this is it. Residents of Provo, many of them Mormons who don't smoke or drink, are among the healthiest in the country... Until recently, Provo seemed to be a model for the nation. But spending on Medicare patients here has accelerated rapidly, as it has in many other areas of the country that are known for cost-efficient care. The culprit: a swift increase in the number of procedures and tests being performed - a trend that has coincided with the additions of new surgical and cancer treatment suites and diagnostic machines at hospitals and clinics throughout the growing region."

(National Public Radio headlined its story on Provo this way: "Provo Leads the Nation in Osmonds and Shoulder Surgery.")

Now, I am not picking on the undoubtedly good people, doctors and patients alike, who live in Provo or McAllen. But it does seem to me that the answer to "bending the cost curve" is going to have less to do with federal legislation than changing a culture of medicine that encourages over-use of health care services, which seems to be linked, at least in part, to physician ownership of diagnostic facilities - something found in both Provo and McAllen, communities that couldn't be more different, except that they spend more per patient.

Changing culture has less to do with the federal government than physicians showing leadership at the national and community levels to re-define what are acceptable practices - what Gawande calls "a battle for the soul of American medicine" - which when you think about it, is a fundamentally conservative idea.

Today's questions: Do you think we should look to Washington "to bend the cost curve" or to changing the culture of medicine in our own communities? And if is culture, how can it be changed?

Thursday, May 20, 2010

"Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it."

From: A.A. Milnes "Winnie the Pooh and the House at Pooh Corner"

Internists, I expect, will identify with Edward Bear.

Richard Baron's study in the NEJM on the amount of work he and his colleagues do outside of an office visit - the bump, bump, bump of a busy internal medicine practice - has resonated with many of his colleagues. Jay Larson, who often posts comments on this blog, did a similar analysis for his general IM practice in Montana, and found that for every one patient seen in the office, tasks are done for 6 other unscheduled patients. Jay writes "So really there [are] internists [who]are managing about 130 patients per day. Not much consolation when they only get paid for 18 per day."

The "bump, bump, bump" of everyday practice include:

- Prescription renewals and pharmacy call-backs

- Calls to family care-givers

- Return calls to worried patients

- Review of lab studies

- Follow ups with consultant physicians

- Pre-authorization requests from insurance companies

- 15 minute office visit on top of 15 minute office visit, all while dealing with the other bumps of a harried day.

And what do they get paid in return? $65 for a mid-level office visit (Medicare payment rate).

The good news is that people are beginning to think of ways to finance and organize primary care that - that at least in theory - would improve outcomes and reimbursement, lower costs, and increase patient and physician satisfaction. These include patient-centered medical homes and accountable care organizations. Common elements of these models include:

- Team-based care under a physician's supervision, so that some of the bump, bump, bump work of physicians might be managed by an advance practice nurse, physician assistant, or other qualified non-physician, allowing physicians to spend more time with the more complex patients who really need to be seen by them.

- Paying physicians for to the work outside of an office visit and for achieving better outcomes, efficiently, to reduce the bump, bump, bump of having to generate an office visit in order to get paid.

- Better care coordination, to reduce the bump, bump, bump of duplicate testing, unnecessary referrals and return visits, and incomplete information sharing between a patient's primary care physician and other specialists involved in their care.

The challenge with these models, though, is that internists are so busy taking care of their patients, in a system that undervalues their work and imposes way too many bumps to the back of their heads, to stop bumping for a moment and think of a better way.

Today's question: Is there another way to organize care that would involve fewer bumps to the back of internists' heads, if only we could stop bumping for a moment and think of it?

Wednesday, May 12, 2010

Just the other day, I was skimming through the FM dial as I drove my rental car from Hattiesburg to the airport in Jackson, following a combined ACP Mississippi/Louisiana chapter meeting. Along with the Sunday morning preachers and stale classic rock, I came across a broadcast that caught my attention: Someone (I never heard the name) was ranting about the American Medical Association's support for health care reform.His gist was that the AMA "sold out" doctors by supporting enactment of "ObamaCare" in order to protect its "monopoly" on the CPT coding system.

He also accused the AMA of trying to "gag" physicians from telling patients about how they would be harmed by the legislation, echoing a Wall Street Journalop-edthat accuses the AMA of "now trying to silence doctors who oppose it."(In fact, the AMA didn't try to gag anyone, but expressed concern about a Florida urologist who put up a signtelling patients who voted for President Obama to go "elsewhere" for their care.)

This is just one of the many barbs directed at the AMA for its decision to support enactment of the Patient Protection and Affordable Care Act (PPACA). There is no doubt that some doctors are angry, very angry, at the AMA. A blog search comes up with dozens of posts about how the AMA has betrayed doctors.It is almost as if the AMA has become the devil incarnate in some doctors' minds.

There is a remarkable degree of incoherence in the criticisms.Many people who decry Harry Reid's "backroom" deals to get the legislation passed apparently see no contradiction in blasting the AMA for not negotiating its own deal to get tort reform passed or the SGR repealed.

Some say that AMA "sold out" doctors - but then say they got nothing in return.Which is it? Some criticize the AMA for being too cozy with primary care at the expense of other specialists, others for being too close to specialists at the expense of primary care. Which is it? The AMA-financed RUC, which recommends relative values to the CMS and other payers, is a favorite whipping boy, even though the PPACA requires HHS to establish a process, outside of the RUC, to review the accuracy of relative values. (This wasn't one of the provisions in the law that the AMA favored, but AMA ended up supporting the overall legislation, nonetheless.)

It is interesting that some disgruntled internists will cut ACP more slack than the AMA.While in Hattiesburg, an ACP member politely told me he had torn up his AMA membership card in protest, but that he continued to support ACP, even though he disagrees with the ACP’s support for the PPACA.

I am glad, of course, that many internists who disagree with ACP's position on health reform remain loyal to the organization.And although it isn't my job to defend the AMA, I am bothered that the invective directed at the AMA always assigns the worst possible motivations behind the association’s actions.It isn't a case of just disagreeing with the AMA's stances, but of assuming that the AMA was motivated by crass and venal self-interest or by a cynical political agenda that put its own leaders' interests above its physician members.

This does not square with the people I know who are in the leadership of the AMA.People like Cecil Wilson, MD, MACP, the incoming President of the AMA, a private practice internist from Winter Park, Florida (and former chair of the ACP Board of Regents), one of the most principled physicians I know.Or Jim Rohack, MD, FACP, the outgoing AMA President, and Nancy Nielsen, MD, FACP, past-president of the AMA--all doctors of character and principle.Or the AMA staff in Washington, who work tirelessly to represent AMA members' interests in Washington. The AMA didn't get everything it wanted - who did? - but it did its best to represent its members' interests and the policies given to it by its House of Delegates.

The critics of the AMA might entertain this thought: Maybe, just maybe, the AMA supported health care reform because getting 95% of all Americans covered was the right thing to do.

I think it the AMA showed enormous character, courage and leadership by supporting the final bill, even as it knew that physicians and the public were divided and that they would likely lose some members as a result.

Today's question: What do you think about the AMA's actions on health reform?

Tuesday, May 4, 2010

"Bold changes are needed in how the United States delivers and pays for primary care if the key goals of national health reform are to be achieved" according to the health policy journal Health Affairs, which today released a thematic issue devoted entirely to the crisis in primary care. (The complete articles are available only to subscribers, but Health Affairs'blog has a good summary.)

I have spent much of the day reading the journal - 47 articles, and a combined three hundred pages of text. My "take-home" messages from the articles:

1. There is a broad consensus that primary care is in crisis. (As an aside, I remember that some said that ACP was being alarmist when in 2006 we predicted that primary care was heading for collapse. Now it has become the conventional wisdom.)

2. The solution is not as simple as training more primary care physicians and paying them more, but to re-invent primary care itself. Susan Dentzer, the editor of Health Affairs, writes that "primary care is maddeningly struck in a by-gone era." Joel Howell reflects on the past and future of primary care, and that the question is not "Will primary care be re-invented" but rather, "How will primary be care be re-invented?"

3. The prescription to re-invent primary care recommended by most of the authors is team-based primary care, usually around a Patient-Centered Medical Home - although several of the articles discussed the need for more rigor in defining the necessary elements for PCMHs to be successful, the best mix of payment incentives needed to support them, the importance of putting more emphasis on features that matter to patients. Yet the articles recognize the potential of PCMHs to improve care and make primary care more attractive to clinicians. Two years after into adopting the PCMH model, the Seattle-based Group Health Cooperative reports on marked improvements in patients' experiences, quality and clinical burn-out.

4. Team-based care means much more than physicians. David Margolius, a medical student at Brown, and Thomas Bodenheimer, professor of family medicine at UCSF, write that "a transformed primary care practice must redefine the physician role such that the physician no longer sees all patients assigned to the practice but as a leader for a well-trained, highly functioning primary care team." Another article advocates for "unleashing" nurse-practitioners' potential to deliver primary care and lead teams - including eliminating state "barriers" to independent practice. Christine Sinsky, MD, FACP, writes about how her Iowa practice has developed a team-based model of care with community-based NPs. Lawrence Casalino argues that the typical workday of primary care physicians needs to be completely transformed, so that instead of seeing a high volume of patients, they would spend more time with those who actually need it.

5. Most of the articles agree that primary care physicians need more pay. One article suggests that narrowing the gap between primary care physicians and other specialties would require increases in primary care physicians' practice incomes, or substantial reductions in specialists' incomes, or both, of more than $100,000 per year. But others argued that primary care clinicians should be paid more only for doing things differently than they do today - that is, delivering patient-centered team-based care that achieves better outcomes.

The attention to the primary care crisis and potential solutions is a good thing. I wonder, though, whether primary care physicians "in the trenches" really want to have their practices re-invented. Most physicians, in my experience, are rugged individualists, and resist the idea of practicing as a member of a team. Moving away from what one article calls the "tyranny" of the 15 minute office visits sounds like a good idea - but figuring out how to get there, and sorting out the respective roles of every member of the team, is another thing. And no matter what, we need a viable payment model that supports, sustains, and nurtures the value of primary care internal medicine.